Perioperative visual loss after spine surgery: a systematic review of risk factors and report of a reversible case.

BACKGROUND: Perioperative visual loss (POVL) is a rare but devastating complication of spinal surgery, most commonly associated with posterior ischemic optic neuropathy (PION) and central retinal artery occlusion (CRAO). Its pathophysiology remains multifactorial and incompletely understood. METHODS: A systematic review of the English-language literature was conducted using MEDLINE/PubMed and Scopus according to PRISMA guidelines. Studies reporting POVL after spinal surgery were included if they provided sufficient clinical, surgical, intraoperative, or outcome data. An illustrative reversible case was also reported according to CARE guidelines. RESULTS: Thirty-nine studies were included, comprising 76 patients. PION was the most frequent subtype (34.7%), followed by CRAO (33.3%), unspecified ischemic optic neuropathy (18.1%), cortical blindness (8.3%), anterior ischemic optic neuropathy (4.2%), and central retinal vein occlusion (1.4%). Visual loss was bilateral in 22.2% of patients. Overall prognosis was poor, with no recovery in 66.2%, partial recovery in 22.1%, and complete recovery in 11.8%. Median estimated blood loss was 1200 mL, with a mean hemoglobin reduction of 4.02 ± 2.24 g/dL. Significant differences among POVL subtypes were found for operative time and duration of prone positioning (p < 0.01), with the highest values in PION. Estimated blood loss was also significantly associated with PION subtype (p < 0.01), and postoperative anemia was most frequent in cortical blindness and PION. Steroids were the most commonly reported treatment, although no association between treatment and recovery was identified. CONCLUSIONS: POVL after spinal surgery is a multifactorial complication with predominantly poor outcomes. Hemodynamic impairment, anemia, prolonged prone positioning, blood loss, and fluid management appear central to its pathogenesis. The illustrative case suggests that reversible forms may occur, supporting a broader pathophysiological spectrum. Prevention remains the cornerstone of management.